Episode #7: Becky Mueller, PA in Palliative Care
Becky Mueller, is a certified PA, trained in Chicago and has spent her career in Ontario, holding roles in both curative-intent oncology and palliative care across Owen Sound and Brampton. This episode documents the clinical, operational, and emotional dimensions of palliative care PA practice, including evidence-based arguments for earlier palliative referral, scope delineation between PAs and NPs, and the structural gap in palliative care access across the GTA.
Becky details how she independently built and managed a home-based palliative service within a Brampton private family practice, covering patient scheduling, advance care planning documentation, symptom management protocols, and 50/50 on-call coverage with her supervising physician.
WHAT YOU’LL LEARNHow palliative care differs from hospice and end-of-life care
Why earlier referral produces measurably better patient outcomes
What the the operational structure of a home-visit palliative PA practice looks like, including patient load, scheduling logic, blood work decision-making, and on-call management
How to navigate the prescribing limitation for narcotics as a PA (in Ontario) and maintain an effective working relationship with your supervising physician
Non-negotiable traits for anyone considering the palliative care path
GUEST BIOBecky completed her PA training in Chicago, graduating in 2010, and has practiced in Ontario throughout her career. Her early clinical work at an Owen Sound oncology clinic included both curative-intent and palliative patient populations, providing the foundational exposure that oriented her toward palliative care as a specialty focus.
Becky subsequently joined a private family practice in Brampton, where she designed and implemented a dedicated palliative care service that had no prior infrastructure. Her scope included home-based patient visits, advance care planning, symptom management. She also does shared 24-hour on-call coverage, serving patients with advanced cancer, dementia, and end-stage cardiac, renal, and hepatic disease.
In addition to direct clinical practice, Becky contributes to PA professional development through Meet the PAs podcast and PA Helpers Canada, with a focus on expanding PA representation in palliative care across Canada.
ON END OF LIFE DIGNITY AND ACCESS“If there's ever a time in life that you deserve the best care, it is during your end of days. Everybody deserves to die peacefully, quietly, and without pain. Right now in Canada, that is not happening.
About 40% of patients who asked for palliative care did not receive palliative care before they died. There are not enough palliative care teams in the GTA.”
— Becky Mueller, PA in Palliative Care
ON DYING AT HOME“Patients have routinely been surveyed again and again in both Ontario and throughout Canada, and consistently the vast majority of people wish to spend their last days at home. Everybody has the right to die at home, but not everyone knows they have that right.”
— Becky Mueller, PA in Palliative Care
ON HOPE IN PALLIATIVE CARE“There can always be hope. Not necessarily hope of a cure, but hope of reconciling differences within family members, hope of reconciling faith. Hope to not have pain, hope to die peacefully, hope to die calmly in your sleep. There are so many parts of hope that can still be established and supported in the palliative setting.”
— Author
ON DYING IN HOSPITAL“Hospitals are not where patients should go to die. Patients need peace and quiet. We've looked at brain waves even when patients aren't able to verbally communicate. They respond better when we have calm, quiet environments.”
— Becky Mueller, PA in Palliative Care
ON GRATITUDE IN PALLIATIE CARE“I felt so welcomed into people's private homes and very vulnerable private moments of life. In palliative care, everybody is grateful despite the very difficult time they're going through and the many emotions they're experiencing.”
— Becky Mueller, PA in Palliative Care
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Defining Palliative Care and Its Early Benefits
Anne [0:00] Today with Becky Mueller, who is part of Meet the PA's podcast as well as PA Helpers Canada. Thank you for being here, Becky.
Becky [0:09] Thanks for having me.
Anne [0:10] Of course. Can you tell us a little bit about yourself?
Becky [0:14] I'm a physician assistant. I graduated in the States — I trained in Chicago in 2010 and have been practicing ever since, mostly in Ontario. I first practiced in Owen Sound, where I focused on active curative-intent oncology patients as well as palliative patients.
Becky [0:44] When I moved to the Brampton clinic, I focused only on palliative patients, the majority of whom were cancer patients. But it also encompassed everyone under the palliative umbrella — end-stage heart disease, kidney disease, liver disease, and so on.
Anne [0:59] And what exactly is palliative care?
Becky [1:02] Palliative care is an umbrella term and it comes with a lot of controversy. A number of people in the field wish to change the term because of the negative connotation it carries. But basically, it refers to anyone who has a life-ending illness.
Becky [1:21] It doesn't have to be immediately life-ending, but it would be something non-curative. Within palliative care there are more specific categories. For example, hospice or end-of-life care covers roughly the last three months. But palliative care broadly can encompass many people over years.
Anne [1:49] And what are some of those other areas? Is it just hospice and end-of-life, or are there other aspects of palliative care?
Becky [1:56] There are definitely other aspects. Most people in the field wish we would see palliative patients much earlier, because most of the time they are referred to a palliative team towards the end stages of life — those last three to six months or so. But many people are diagnosed with a life-ending or non-curative illness years before.
Becky [2:18] For example, Alzheimer's disease and dementia typically take many years to end someone's life. Same with heart disease and kidney disease. Study after study repeatedly shows that those who are referred to a palliative team earlier actually lived longer with better quality of life.
Becky [2:44] We really wish that patients were referred sooner rather than waiting until the end. If we see them sooner, we can address their symptoms and concerns well before the final stage. It certainly doesn't mean we're stopping active treatment — they would continue seeing their cardiologist, nephrologist, or oncologist.
Becky [3:18] The palliative team can be provided anywhere, and it should encompass a physician, either a nurse practitioner or PA or both, nursing staff, social work, physiotherapy, and occupational therapy. The list is really quite broad as to who should be on that team to provide the best support.
Becky's Path and PA Clinical Duties in Palliative Care
Anne [3:44] And how does the PA fall into this role within the palliative care team?
Becky [3:49] It happened a bit accidentally. When I got the job in Owen Sound, I didn't know I had an interest in palliative care. I went there because I liked oncology and I needed a job — those things aligned.
Becky [4:06] Throughout my time there I was exposed to quite a few palliative patients, really enjoyed that work, and felt very blessed to be part of those moments. So I took a second job in Brampton to focus solely on the palliative side.
Becky [4:28] When I took the Brampton job, I actually didn't know it was going to be fully palliative care. I came on through a private family practice, and the original idea was that I'd see some palliative patients alongside regular clinic patients. But after a couple of months it became clear there were plenty of palliative patients who needed my time and that I had a real skill in that area. So I ended up not seeing family clinic patients at all.
Anne [5:14] And what are some of your clinical responsibilities as a palliative care PA?
Becky [5:22] Obviously there's the paperwork side. Everyone will talk about DNR status — and by the way, a DNR is not required to receive palliative care. It is 100% optional based on the patient's wishes. They do not require a DNR to be under a palliative care service. They would require one to be seen in a residential hospice setting, but otherwise they can be anywhere with a full code if that's their wish.
Becky [5:47] If you don't have a social worker on your team, you'd also help take care of other general medical directive paperwork — what their end-of-life wishes would be. I like to get a bit more detailed than the standard forms, because you want to talk not just about life support and DNR status, but also about things like antibiotics.
Becky [6:21] Do antibiotics potentially save someone's life? They may prolong it for a few days or weeks, but they don't really help with symptom management in the last stages. So that's always up for discussion. We also talk about IV fluids and nutritional status, particularly for patients with GI or pancreatic cancers, where family members often become very concerned.
Becky [7:05] You'd also take care of any admission paperwork to the hospital, hospice, or long-term care facility. Then beyond paperwork, there's the clinical side. You visit patients regularly — sometimes monthly, sometimes daily in those last stages — and do a full physical exam, manage symptoms, order blood work, and coordinate care.
Becky [7:54] I didn't have to do many procedures personally, but one that would be very useful in the palliative setting is bedside paracentesis. If you have that skill, patients don't have to go into a facility to have it done, which is a real advantage.
How PAs Interact with Patients and Families in Palliative Care
Anne [8:16] And how does this role look different from what a physician or nurse practitioner would do?
Becky [8:24] In my opinion, the NP and PA roles are very similar, and patients and families rarely can tell the difference. The main technical distinction is prescribing authority. Palliative care patients require a lot of narcotics — pain control is the primary concern at end of life — and PAs cannot prescribe narcotics at this time. Nurse practitioners have some ability to do so, and physicians are the main prescribers.
Becky [9:04] However, I never felt that was a real hindrance to my work. I could text or call my supervising physician and say, "I just saw this patient, their pain is at this level, here's what I'm thinking in terms of adjusting the short-acting and long-acting medications." Our working relationship was strong enough that he'd write the script. It wasn't an issue.
Anne [9:49] And what should a patient expect when interacting with a PA?
Becky [9:56] They should expect someone who is very empathetic and a very good listener. The day-to-day physical exam isn't really different from any other PA practice — but the key difference in palliative care is someone who can sit down, truly empathize, and listen. A lot of times what patients and families need most is someone who will sit with them for an hour, hear their concerns, and either validate those concerns and explain how they can be alleviated, or help explain why something may not need to be the main concern.
Anne [10:49] And how do you interact with families in palliative care?
Becky [10:54] Much the same way as in other settings, though families are very involved in palliative care. Similar to a pediatric population, they have to be taken into consideration. We schedule family meetings in advance so that members who are working or out of town can attend and have their questions addressed. Patients are often more concerned about how their family is coping than about their own condition.
Becky [11:38] At the same time, we always have to be sure we're still respecting the patient's privacy, autonomy, and wishes around what they want shared or not shared.
Anne [11:52] You mentioned a few conditions like Alzheimer's and cancer. What are some other diagnoses that come through palliative care?
Navigating Emotional Challenges and Finding Hope in Palliative Care
Becky [12:04] The most common was advanced cancer. Dementia was also extremely common, and it's very hard because it can take many years to end someone's life. No family member wants to say they wish it were shorter, and patients don't either — but living with that continual deterioration is very difficult. We need extra supports in place to help manage it.
Becky [12:55] It's also very difficult to estimate when a dementia patient is near the last weeks to months of life, because the illness has such a slow course. They often plateau and stay in that state for a long time. End-stage heart disease, liver disease, and kidney disease are also very commonly seen. ALS and other neurologic diagnoses would qualify too, though those were less common in my practice.
Anne [13:40] And what were some of the positives or benefits of working as a PA in palliative care?
Becky [13:46] I think it's one of the best areas to work. You have some of the most rewarding patients. Not only do you feel like you're making a real difference day to day — you're directly impacting quality of life — but patients and families are genuinely grateful. I felt so welcomed into people's private homes and into very vulnerable moments of life.
Becky [14:24] When I covered family practice or urgent care, you don't get that same kind of reward. People sometimes walk away angry because they didn't get the prescription they came in wanting. In the palliative setting, everyone is grateful despite the incredibly difficult time they're going through.
Becky [14:42] That said, it is emotionally demanding. You have to be someone who can manage those emotions. It's not about suppressing them — it's OK to feel sad, it's human. But you have to be able to prevent those emotions from taking over your life. That is a skill. I don't think you're necessarily born with it, and many people can learn it, but it has to be something you're conscious of.
Becky [15:19] You need a way to go home at the end of the day and replenish yourself. There are now programs designed to help any clinician in a palliative setting manage that emotional weight. Death is a part of life we will all experience. But we enter healthcare with the goal of fixing people, so when you can't fix the original problem, that can be a challenge.
Becky [16:11] There can always be hope — not necessarily hope of a cure, but hope of reconciling differences within families, hope of reconciling faith. You see that often. People who spent years away from their faith may come back to it in those final moments, and can reconcile emotional issues that had been unresolved for many years — not just the patient, but family members too.
Becky [16:40] There's hope to be free of pain, hope to die peacefully, hope to pass calmly in one's sleep. There are so many forms of hope that can still be established and supported in the palliative setting — it's not just about hope for a cure, which is the only kind we tend to think about. And there are now a lot of support programs in place for clinicians who practice in this space to help them deal with those emotions and continue forward.
Inside a Palliative Care PA's Daily Home Visits
Anne [17:14] Can you describe what a typical day would look like for a PA in palliative care — at least in your experience?
Becky [17:23] I would travel. Most of my patients I was not seeing in clinic because most were too ill. So I'd travel to patients' homes as well as to the residential hospice. I didn't travel to the hospital because the Brampton hospital unfortunately did not grant me authority there — that was a different battle. My physician handled those visits.
Becky [17:45] I would see roughly 10 patients in a day and keep one or two spots open for emergency or urgent visits. That might sound like not many, but I wanted to allot as much time as each patient needed. Sometimes it's a quick visit, sometimes it's an hour and a half.
Becky [18:23] There's also travel time between homes and sites to account for. I scheduled everything myself rather than using front desk staff — it was just too complicated. I needed to schedule by urgency as well as by physical location, so I wasn't backtracking across the city. I'd typically start closest to the clinic and move outward through the day.
Becky [19:23] I'd allot roughly an hour per patient. You assess them, you chat, you check in on how they're doing — always assessing pain, performance status, nutritional status, bowel habits, bed sores, and any other specific symptoms. Then I'd do an exam and order blood work if needed.
Becky [20:01] I'm very conservative on blood work. If it's not going to change our overall position, there's no reason to order it. For example, I wouldn't routinely check creatinine on a patient in end-stage renal failure when I already know the result won't be good and it won't change anything I'm doing. Same with electrolytes — I'd stay away unless we knew there was something we would actually treat.
Becky [20:53] What I wouldn't be conservative on was anything that would keep patients comfortable. If a paracentesis was going to help, I'd make sure it got ordered and the patient got scheduled. I'd make whatever phone calls were needed. I also maintained close contact with the nursing teams doing home visits to make sure everyone was aligned.
Why Patients Prefer Home Care Over Hospital for Palliative Needs
Anne [21:15] What difference does it make for patients to receive care at home from a provider like yourself versus being in the hospital?
Becky [21:23] Patients have been surveyed repeatedly across Ontario and throughout Canada, and consistently the vast majority wish to spend their last days at home. That alone makes it better. It's where they want to be, and patients deserve to be there. They're already living with a life-ending illness and all the symptoms that come with it — we should alleviate everything we can, including location.
Becky [21:59] Everyone in Canada has the right to die at home, but not everyone knows that. And of course the logistics can get complicated. Funding for home care varies across provinces and even within different districts of the same province. Some areas can provide visiting nurses multiple times a day, while others might only fund one or two visits a week. That gap has to be filled by family members or private finances.
Becky [22:52] It does happen more frequently when a palliative team is involved, because we know the resources and can connect patients and families to them. We help support the whole system, and obviously home visits make a real difference. We need patients to be passing away at home if that's where they want to be.
Becky [23:10] The other thing is that hospitals are not where patients should go to die. Hospitals are where patients go to get better and receive acute treatment. The idea is you get in, you get treated, and you get out. Hospitals are more likely to cause infection, and they're loud — that's not really avoidable. Patients at end of life need peace and quiet.
Becky [23:56] We've researched this and have even looked at brain waves in patients who can't verbally communicate — they respond better in calm, quiet environments. A hospital simply cannot provide that. Buzzers, overhead announcements, beeping machines. And patients are more likely to receive interventions they may not want, like blood draws at 5 AM, which is just not conducive to a peaceful final few days.
Becky [25:02] There are hospitals that have hospice settings for areas without a residential hospice, where they convert a room or section. It's sometimes necessary and unavoidable, especially when symptoms can't be managed at home. They do their very best — but the rooms are typically smaller, there isn't always enough space for family, and it's just not the same.
The Serene Environment and Challenges of Residential Hospice Care
Anne [25:40] Can you clarify what a hospice is?
Becky [25:44] There are two definitions. Hospice in general refers to care during the last few weeks to months of life. A residential hospice, however, is a physical facility you would go to during that time — and they're really lovely spaces. If it's not possible for someone to pass away at home, a residential hospice is fully covered by the government.
Becky [26:14] You get a very large room, usually with a pull-out couch so family can stay overnight, a large bathroom, and often access to a garden — a peaceful, quiet, beautiful space. There's typically a children's room or play area, food for family members, usually volunteer staff who cook for families, and showers and other facilities so family members who are there for extended periods can stay comfortable.
Becky [27:04] The challenge is that bed space is very limited. Because the rooms are so large, they can't accommodate the numbers a hospital can. The hospice in Brampton I worked with had 10 beds. So there's a waiting list, and sometimes there's time to wait for a space to open — and sometimes there isn't.
Becky [27:46] But they're really beautiful places and I've not had a single complaint. The only real challenges I ran into — beyond bed availability — were language and cultural barriers. They did their very best to accommodate, but they couldn't guarantee that a nurse who spoke the patient's language would be on shift at every hour of the day. That was something the hospice was fully aware of and actively working to address.
How PAs Enhance Access and Services in Palliative Care
Anne [28:35] What difference do you find a palliative care service notices with a PA on the team?
Becky [28:45] It helped provide 24-hour phone coverage. My supervising physician and I split call 50/50 — obviously with him always on backup when I was on call. But PAs are very capable of managing the vast majority of issues that come through, especially with good planning. I think there was maybe one time in my entire on-call period where I needed to phone him. We were able to provide a true 24-hour service to our palliative patients, which is a big deal. That level of access is really non-negotiable in quality palliative care.
Becky [29:38] We also visited patients more regularly. If they called that day with an issue, they received care that same day — and that was not happening before I was there. That access piece is the biggest difference patients experienced.
Becky [30:01] The other thing is that many family physicians aren't running a dedicated palliative care service. The palliative care service I was part of in Brampton was 100% built by me. Supported by my physician, absolutely — but it didn't exist before I arrived. There simply aren't enough palliative care teams in the GTA.
Becky [30:35] There's a study that came out about six months ago citing the number of patients who wanted palliative care but did not receive it before they died. I don't want to misquote the exact number, but I believe it was around 40% of patients who asked for palliative care did not receive it before death.
Anne [30:50] It seems like PAs are an untapped resource in helping family physicians expand access to palliative care. Do you see this as an area for growth?
Becky [31:04] Absolutely. It doesn't receive a lot of focus in conventions or in school, but it really needs to. Nurse practitioners are more commonly found in palliative care than PAs right now, but that's mostly because they've been around longer as a profession. There's no reason they need to dominate that space over us.
Becky [31:38] In fact, PAs might actually be a better fit in some contexts, because physicians in patient care often want to maintain a relationship with their patients but don't have the time to be there with every single one in the same way. Because PAs function more as physician extenders rather than independently, we tend to have a closer, more collaborative relationship with the physician, which can really work in the palliative setting.
Becky [31:59] I'll add the caveat that I really think NPs and PAs can function equally successfully in this role — and both professions should be more involved. If there's ever a time in life when someone deserves the best care, it's at the end. Everybody deserves to die peacefully and without pain. Right now in Canada, that is not happening for everyone.
Becky [32:16] Canada is a leader in palliative care globally, but we're not there yet. We still have a long way to go.
Anne [32:30] If a physician or a local health integration network were interested in incorporating a PA onto a palliative service, what are some first steps?
Becky [32:47] I'll be honest — I'm not entirely sure of the logistics of how LHINs hire PAs specifically. But they're already hiring PAs, so it's not an insurmountable task. The real step is recognizing that palliative care needs PAs, and then devoting funding toward it. After that, you'd hire just like you would for any other practice. The key is finding the right fit, because the medical piece of palliative care isn't that complicated — anyone who passed their qualifying exams can learn it. The harder piece is the emotional one.
Becky [33:44] The first step, really, is recognizing that this is a need — and I don't think many private practices or LHINs have actually done that yet. So it falls to us, as PAs, to be networking and advocating for our profession and for these patients.
Essential Tips for PAs and Palliative Care Resources
Anne [34:11] To round out our discussion — what tips would you give to students or PAs who are interested in palliative care? What characteristics should someone have or be prepared to develop?
Becky [34:36] First, learn the medicine of it — which, like I said, is not that hard. You can learn it on the job. Anyone who has graduated and passed the exam is capable of learning how to manage the symptoms involved in palliative care.
Becky [34:55] The harder piece is working on your listening skills. It's something I still have to work on. And alongside that, you have to check in with yourself emotionally on a regular basis. Anyone going into this role has to understand upfront that emotional self-management is the piece they'll continuously be working on. Even if you're really good at it now, at some point you'll need to reassess.
Becky [35:13] Whether that looks like taking time off, staying engaged with your hobbies, meditating, going for walks — find what works. Self-awareness works really well for me. I also rely on my faith. If you're not faith-based, that's fine — you can absolutely work in palliative care — but you do need some way of tending to your spiritual and emotional self throughout the process, which anyone can develop.
Becky [35:53] You also have to be aware of the discomfort that colleagues in other specialties sometimes have around death and end-of-life care. Learning to stay calm when that comes up — and not taking it personally or bringing it home with you — is its own skill. I've struggled with that myself, but many people can overcome it.
Becky [36:13] On the whole, I think Canadian clinicians are making progress. Most are at least aware of the basics and do acknowledge patient autonomy. And with so much news coverage of MAID — Medical Assistance in Dying, which was legalized in 2016 — more people are thinking about these issues more carefully. PAs are not permitted to carry out MAID, but nurse practitioners and physicians can. Most practitioners do support patients' right to choose how they die.
Becky [37:34] MAID is legal across Canada, but there are still a lot of complexities being worked out. The fact that it's been so widely covered in news across the country has made clinicians more aware and more open to thinking about it.
Anne [37:47] Is there anything else you wanted to touch on or add?
Becky [37:51] I hope people find this helpful. I hope some consider going into palliative practice. And even if you don't dedicate 100% of your practice to it, almost everybody has palliative patients somewhere in their caseload — family practice, internal medicine, oncology, neurology, cardiology. You can incorporate palliative care principles into your practice daily. The biggest thing is just listening to patients, making them aware of their choices, and supporting those choices.
Anne [38:39] And for anyone interested in learning more — about palliative care, its principles, or how it's practiced in Canada — where's a good place to start?
Becky [38:48] The Physicians and Palliative Care group — they're a national Canadian organization, led in part by family physicians and specialized palliative care physicians. They do research across Canada, work to connect with government, and raise awareness both publicly and within hospital and clinic settings. They put out guidelines as well. That's a really good place to start. And I'm always happy to answer questions directly — people can contact me.
Anne [39:31] And they can reach you through LinkedIn or rlmwriting@gmail.com.
Becky [39:36] That's correct.
Anne [39:40] Becky, thank you so much for your time. I'll put everything in the show notes so everyone can find ways to get in contact with you.
Becky [39:51] Thank you so much and thanks for having me on.
